STUDENT INFORMATION
Last Name
*
First Name
*
M.I.
Birth Date
*
-
Month
-
Day
Year
Date Picker Icon
Gender
Please Select
Male
Female
Grade completed
*
Have you previously attended VBS?
Yes
No
If yes, what year?
Home Church (if any)
Street Address
*
Street Address Line 2
*
City
*
Postal Code
*
Primary Phone Number
*
Secondary Phone Number
EMERGENCY CONTACTS
Please list the first and last names and phone numbers off ALL adults who are allowed to pick up this child. The child will only be released to these people.
Primary Guardian
*
First Name
Last Name
Relationship to child
*
Phone Number
*
-
Area Code
Phone Number
Alternate Guardian #1
*
First Name
Last Name
Relationship to child
*
Phone Number
*
-
Area Code
Phone Number
Alternate Guardian #2
First Name
Last Name
Relationship to child
Phone Number
-
Area Code
Phone Number
Medical Information
Please list all allergies -- or type "none" if there are none
*
Does your child carry an epi-pen? (please note: if yes, it is the responsibilty of the child's guardian to ensure the child has the epi-pen at every drop off and pick up)
*
Yes
No
Please list all medical concerns -- or type "none" if there are none
*
VBS photos/videos are taken for promotional purposes related to The Awakening Muhlenberg and Vacation Bible School. These pictures appear on our facebook page and webpage. Do you allow your child to be included in these photos/videos?
*
Yes
No
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By submitting this form, I ackowledge I have read and understand the above information.
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